INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically buprenorphine, in the residential detoxification from opioid dependence. This inspection was conducted on January 12, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run, Inc.- Lancaster was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on February 7, 2009.
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Plan of Correction
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715.17(c)(3)(i-v) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(3) Inspection of storage areas. A narcotic treatment program shall inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State and local laws and regulations. A narcotic treatment program shall develop and implement written policies and procedures regarding who performs the inspections, how often, and in what manner the inspections are to be documented. The policies and procedures shall include the following:
(i) Disinfectants and drugs for external use shall be stored separately from oral and injectable drugs.
(ii) Drugs requiring special conditions for storage to insure stability shall be properly stored.
(iii) Outdated and contaminated drugs shall be removed and destroyed according to Federal and State regulations.
(iv) Administration of controlled substances shall be documented.
(v) Controlled substances and other abusable drugs shall be stored in accordance with Federal and State regulations.
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Observations
Based on the review of administrative documentation and discussion with the QI director, the facility failed to complete the quarterly inspections of the drug storage areas.
The findings include:
The medication storage area was inspected and the documentation of the inspections of the storage areas was reviewed on January 12, 2009. In 2008, the medication storage area inspections were due March, June, September and then January 2009. An inspection was documented in March 2008 and the next was done October 1, 2008. January 2009 was completed.
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Plan of Correction
The facility contracts with a pharmaceutical company to conduct independent quarterly inspections of the medical storage area. To ensure that inspections are conducted on a quarterly basis, the Regional Administrator and the Northeast Director of Quality and Nursing Services will schedule a quarterly internal audit of the medication area in addition to the independent audit to serve as a secondary means on ensuring that inspections are completed on-time. The quarterly inspection dates will also be entered into the annual calendar of events at the facility to provide advance notice of upcoming inspections, and the regioanl administrator will maintain on-going communication with the pharmacy to ensure that the independent audit is conducted within the quarterly timeframe. An inspection did occur in Jan 2009. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on the review of patient records, the facility failed to complete a discharge summary in two of two patient records.
The findings include:
Five patient records were reviewed on January 12, 2009. Discharge summaries were required in two patient records. The facility did not document the discharge summary within seven days of discharge in patient records # 4 and 5. Patient # 4 was discharged November 8, 2008 and a discharge summary was not completed. Patient # 5 was discharged October 27, 2008 and the discharge summary was not done until November 29, 2008.
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Plan of Correction
The facility shall complete all client discharge summaries within seven days of the patient being discharged from the program. Nursing staff will be re-trained by the Regional Administrator and Nursing Coordinator on the proper policy and procedure for completing all detoxification discharge documentation. Additionally, the Regional Administrator and Northeast Director of Quality and Nursing Services will conduct on-going random reviews of discharge summaries to identify any concerns and communicate these to the medical staff. |